Guidelines for Prevention and Treatment of Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Opportunistic Infections in HIV-Infected Adults and Adolescents Adults and Adolescents Cryptococcosis Slide Set Cryptococcosis Slide Set Prepared by the AETC National Resource Center based on recommendations from the CDC, National Institutes of Health, and HIV Medicine Association/Infectious Diseases Society of America
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Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Cryptococcosis Slide Set Prepared by the AETC.
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Guidelines for Prevention and Treatment of Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Opportunistic Infections in HIV-Infected Adults and AdolescentsAdults and Adolescents
Cryptococcosis Slide SetCryptococcosis Slide Set
Prepared by the AETC National Resource Center based on recommendations from the CDC,
National Institutes of Health, and HIV Medicine Association/Infectious Diseases Society of America
May 2013 www.aidsetc.org2
About This PresentationAbout This Presentation
These slides were developed using recommendations published in May 2013. The intended audience is clinicians involved in the care of patients with HIV.
Users are cautioned that, owing to the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
Flucytosine increases rate of CSF sterilization during induction therapy
Consolidation therapy should not be started until ≥2 weeks of successful induction therapy: Significant clinical improvement Negative CSF culture on repeat lumbar puncture
Fluconazole more effective than itraconazole for consolidation therapy
Elevated intracranial pressure (ICP) associated with cerebral edema, clinical deterioration, and higher risk of death More likely if >25 cm H2O
Opening pressure always should be measured when lumbar puncture (LP) is performed
Management of elevated ICP: Daily LP with removal of CSF, or CSF shunting if LP
is not effective or not tolerated Corticosteroids, mannitol, and acetazolamide are
not recommended
May 2013 www.aidsetc.org17
Cryptococcosis:Cryptococcosis: ART InitiationART Initiation
Optimal timing for ART initiation is not clear – small studies have reported increased morbidity/mortality with very early ART
For patients with severe cryptococcal CNS disease (especially if ICP is elevated), it may be prudent to delay start of ART until induction or consolidation phase is completed (2 or 10 weeks)
For patients with advanced AIDS (CD4 <50 cells/µL), earlier ART initiation may be needed
If ART is started early, monitor closely for signs/symptoms of IRIS (eg, elevated ICP)
Secondary prophylaxis: Lifelong suppressive treatment (after completion of initial
therapy), unless immune reconstitution on ART Preferred: fluconazole 200 mg QD
Consider discontinuing maintenance therapy in asymptomatic patients on ART with suppressed HIV RNA and sustained increase in CD4 count to ≥100 cells/µL for >3 months, after ≥1 year of azole antifungal chronic maintenance therapy
Restart secondary prophylaxis if CD4 count decreases to <100 cells/µL
May 2013 www.aidsetc.org24
Cryptococcosis:Cryptococcosis: Considerations in PregnancyConsiderations in Pregnancy
Diagnosis: as in nonpregnant women; initiate treatment promptly
Treatment: Lipid formulations of amphotericin B are
preferred for initial treatment (to avoid potential teratogenicity of azoles)
If chronic amphotericin B at time of delivery: evaluate neonate for renal dysfunction and hypokalemia
May 2013 www.aidsetc.org25
Cryptococcosis:Cryptococcosis: Considerations in PregnancyConsiderations in Pregnancy (2) (2)
Treatment: Flucytosine: teratogenic in animal studies; use
only when benefits outweigh fetal risks Fluconazole ≥400 mg/day through or beyond
1st trimester is associated with congenital malformations; FDA Pregnancy Category D; not recommended in 1st trimester unless benefits clearly outweigh risks
May 2013 www.aidsetc.org26
Cryptococcosis:Cryptococcosis: Considerations in PregnancyConsiderations in Pregnancy (3) (3)
Treatment: Itraconazole: limited data, not recommended
in 1st trimester Voriconazole and posaconazole: teratogenic
and embryotoxic in animal studies; should be avoided
May 2013 www.aidsetc.org27
Cryptococcosis:Cryptococcosis: Considerations in PregnancyConsiderations in Pregnancy (4) (4)
Postpartum period may be high-risk period for IRIS
May 2013 www.aidsetc.org28
Websites to Access the GuidelinesWebsites to Access the Guidelines
http://www.aidsetc.org
http://aidsinfo.nih.gov
May 2013 www.aidsetc.org29
This presentation was prepared by Susa Coffey, MD, for the AETC National Resource Center in May 2013
See the AETC NRC website for the most current version of this presentation: